Non anesthesia provider providing anesthesia

[EMS/ICU/SRNA]

I overheard an ED attending discussing a policy regarding the administration of propofol w/ an RN at work today. Apparently the policy states that propofol or any other medication may be administered to a non-intubated pt if an attending ED/Pulmonary physician is in the room. This would be done for a procedure ie: reduction of a fx....etc. I asked him why anesthesia personnel would not provide the anesthesia. He responded that the ED/Pulmonary physician is able to provide all services that anesthesia could. What do you guys think about this?

[rn29306]

Hey RN

Admit it, you are not giving propofol for CS, you are giving it for unconscious sedation, (ie general anesthesia).

Wow. That is not true at all. I have only once had to bag a patient we gave propofol to. I have only given it in the er maybe 20 times. The intent, and the dose, is meant for concious sedation. Are you suggesting the emergency physicians and ACEP are lying?

And are you telling me that you administer propofol to true CS guidelines?

The traditional role and characteristics of CS have become quite blurred.

CS is defined as the drug-induced depression of consciousness during which patients respond purposefully to verbal command, either alone or accompanied by light tactile stimulation.

Deep Sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.

Listen Mike, we all on this board have worked in hospitals and I have done traditional CS and now with anesthesia done MAC cases, which are essentially IV general cases with spont resps. I know how the lines are blurred and you have to admit that sedation is a continuum. What happens is that people, especially non-anesthesia personnel, sedate patients to the realm of reflexes only responsive to pain and then throw the CS flag. This is complete and utter BS.

"Yep, doc, grannie is breathing but about as arousable as a drunk on St. Paddy's Day in Savannah, better go ahead and set that bone."

If it was true CS you are after, then you wouldn't be using propofol now would you? When GI does cases under CS, they use traditional fent/mid. They call us for propofol which you have to admit goes a little beyond "responding purposefully to verbal commands either alone or accompanied by light tactile stimulation". Not too many people "ride the black snake" and stay on the table during the procedure that respond to "verbal commands" or "light tactile stimulation". This to us is a MAC, not CS.

What is hilarious is that some people claim reflex withdrawal from painful stimulus as a "purposeful withdrawal". Reflex withdrawal from painful stimuli is NOT considered a purposeful response. Thus, reflexive withdrawal is NOT CS, but instead approaches general anesthesia.

Listed as a "patient exclusion criteria" for CS by UMBC is the following:

"Situations where it is anticipated the required amount of sedation will eradicate purposeful response to verbal and tactile stimuli".

To all non-anesthesia providers giving propofol for what you consider CS:

So you are honestly saying that your propofol CS patients "purposefully respond to verbal commands and light tactile touch"?

Where would your patients score on the GCS during your "propofoled CS"? Look beyond your professional organizations, professional and personal agendas and answer the above two questions honestly. I think both you and I know the answer.

[London88]

rn29306 hit it on the nail . There is a difference between concious sedation and what i call general w/out an ETT. We always joke about this where I work because i tell evrybody that i do not do MAC cases all my MACs are generals w/out ETT and I belive that this is what this heated discussion is about.

[deepz]

..... i do not do MAC cases all my MACs are generals w/out ETT ......

RAGs. Room Air Generals.

'Conscious sedation' is one thing; most MACs do end up Room Air Generals. With O2 supplement of course.

!

[jwk]

RAGs. Room Air Generals.

'Conscious sedation' is one thing; most MACs do end up Room Air Generals. With O2 supplement of course.

!

Down here we call 'em Big Mac's

[yoga crna]

By turning this discussion into a turf battle several important points are missed. The points I am about to make, I believe will seconded by seasoned anesthetists.

1. Any type of sedation depends on some type of ANALGESIA or ANESTHESIA if a painful procedure is involved. Sedation type drugs do not take away pain, in fact in some circumstances, they make the pain worse. With the possible exception of ketamine which has analgesic properties, propofol, versed and even narcotcs are not adequate for deep viseral pain. If they were, anesthesia would be a totally different field. The reason why this is important is that non-anesthesia people do not understand that if a patient moves, moans or winces that more sedation is not always the answer. This technique is more of an art than the casual user understands. Also, it is darn near impossible for the operator to also be the anesthetist. I am never impressed when I hear that a gastroenterologist gives propofol and then does the procedure in a dark room looking at a tv screen.

2. Some of my most difficult cases in my career have been sedation cases. Let me put a tube in the airway and I can handle most problems. It may sound simplistic, but ask experienced anesthesia professionals and I expect that most would agree.

3. Most sedation untoward incidents are not reported, especially when they occur in out-of-the-operating room or out of the hospital settings. I would like to know how we could get accurate data.

Yoga CRNA

[rayman]

The last couple of posts got me thinking. Yoga lightly touched on it, but here is my question for you crna's/srna's from a soon to be....seems to me like the big macs, room air generals and general without an ett would be a lot more nerve racking than a straight general anesthestic. It just seems like the line you walk is a lot thinner on a mac than a general. Do you find this to be so?

[austin heart, BSN, RN]

By turning this discussion into a turf battle several important points are missed. The points I am about to make, I believe will seconded by seasoned anesthetists.

1. Any type of sedation depends on some type of ANALGESIA or ANESTHESIA if a painful procedure is involved. Sedation type drugs do not take away pain, in fact in some circumstances, they make the pain worse. With the possible exception of ketamine which has analgesic properties, propofol, versed and even narcotcs are not adequate for deep viseral pain. If they were, anesthesia would be a totally different field. The reason why this is important is that non-anesthesia people do not understand that if a patient moves, moans or winces that more sedation is not always the answer. This technique is more of an art than the casual user understands. Also, it is darn near impossible for the operator to also be the anesthetist. I am never impressed when I hear that a gastroenterologist gives propofol and then does the procedure in a dark room looking at a tv screen.

2. Some of my most difficult cases in my career have been sedation cases. Let me put a tube in the airway and I can handle most problems. It may sound simplistic, but ask experienced anesthesia professionals and I expect that most would agree.

3. Most sedation untoward incidents are not reported, especially when they occur in out-of-the-operating room or out of the hospital settings. I would like to know how we could get accurate data.

Yoga CRNA

Very good post with a few exceptions, lol........

1. As a bedside critical care nurse I am fully aware that sedation does not control pain. I don't know how many times though I have seen a co-worker crank up the diprivan on a moaning, wincing patient when I personally felt that the sedation level was adequate that the patient would relax and be more comfortable with proper pain control. Above scenario is on an intubated patient but could just as easily be a non-intubated ER patient. Even though I am good with my drugs and I feel that I can hang in a crisis situation I feel it prudent to bow to the expertise of the CRNA or anesthesiologist, after all that is what THEY went to school for. I agree with you that the person pushing the propofol then can not monitor the vitals and assist the MD by handing over supplies etc. The sedated patient needs the FULL attention of the person supplying the drugs.

2. It is SO MUCH easier to handle a sedated INTUBATED patient. It is a whole different ball game than pushing propofol on a non-intubated patient. I think that it is like comparing apples and oranges.

3. I really agree that many cases are more than likely going un-reported, especially if there is a fair to good outcome. I think that care providers have a "phew, that was close" attitude but figure that they are safe and all is good if the person doesn't die or suffer serious harm.

I don't understand why these RN feels like that need to be pushing the envelope with their licenses, it's not like they are getting paid more money for that service. It is all too risky for me. I would rather leave it up to the trained aesthesis. Just my opinion.

[deepz]

....seems to me like the big macs, room air generals and general without an ett would be a lot more nerve racking than a straight general anesthestic. .....

Absolutely! See yoga above: "Some of my most difficult cases in my career have been sedation cases."

When the patient is paralyzed and intubated, no big deal. Smooth sailing. Simple. When the patient is sedated BUT has inadequate local anesthesia and/or has a high tolerance to depressants and therefore squirms and cries and struggles thoughout, you end the case feeling as if you carried them on your back the whole time.

For a 90 minute cosmetic case I once gave a patient a total of 20mg Versed, 500 mcgs fentanyl, 100mg ketamine and (seriously, no joke) 2600 mg of propofol. Seems she might have been a bit of a party girl. The Bard InfusOR was dialed up to absolute max flow, plus frequent boluses, and she was still squirmy. To do a general for her would have been SO MUCH simpler. MACs can be a PITA.

deepz

[Pete495]

Also, during MAC cases, there's always that nagging feeling, "boy I hope I don't have to go to a general, cuz this surgeon is gonna be pissed off." If it has to be done, it has to be done, but who wants to tell the surgeon the patient needs intubated when the case is gonna end in 15 more minutes.

[athomas91]

i completely agree - MAC's are the hardest cases there are - you need more airway management skills and understanding than with a general as far as management goes because the goal is not just to "bag em" or intubate... the goal is to maintain an airway, but have them comfortable enough to tolerate a procedure.

i was an ER nurse - there no such thing as conc. sedation in the ER - the procedures are too acutely painful to manage w/ propofol - the are the MACgenerals everyone is referring to.

mmac - you keep calling for evidence - you are hearing the experience of over 50 years of cummulative experience - likely more than that - when you take yoga,jwk and deepz into consideration... that is not anything to snuff your nose at... secondly - as a soon to be grad - take it from me - noone here really has time to go reading research to prove they are right - they've read the research - some of them have done the research - and they have told you time and time again that only school and anesthesia education will prove to you how wrong you are... but you continue to be stubborn about it - the remarks toward you aren't inappropriate or unprofessional - they are opinions about how hardheaded you are being...

would you like the nursing tech you work with to school you on your cardiac gtt's??? probably not...

if you want to believe that just because your hospital administration tells you that it is ok - you are safe -

then go ahead - it is your future. the providers here have just tried to show you that such a belief is misled - but - have it your way...i am telling you i have been where you are - I WAS WRONG....and you can take that to the bank... it may be to write a check to a plantiff...

[yoga crna]

Ok

I am all for the spirit of discussion/debate, argument and professional sabre rattling. Its fun. I also learn alot from it. I enjoy challenging norms and learning the whys behind things. Challenging and asking the questions is how you (I) learn.

What im not ok with are personal and professional attacks directed at me questioning both my competance and ethical practice. This is not only unfounded but unprofessional and not the least of which mean-spirited. It quickly indicates how some react to the inability to defend their position, its classic "i'm right and your wrong and i dont have to prove it" behavior. An oppression nursing has long fought to get out from under yet is perpetuated here on this forum.

Mike,

This is not a personal attack--in fact I enjoy reading your posts. I am going to make a request of you. Save all of your posts and re-read them after you are in anesthesia school one year. It reminds me of my 12 year old grandaughter who I was with today. It was amazing and very amusing how many answers she has about life. I hope I have the opportunity to laugh with her about them in about 20 years.

I do respect your passion to learn and hope that continues through your career. But on the other hand, part of what makes great medical practitioners in all fields, is the ability to follow their instincts as well keeping current with the literature and research.

Yoga

[rayman]

Yep, an administrator will sell you down the river in a heart beat...I've seen it too many times. Saw it last summer, unfortunately. The boss was out so I was the only one left with a clue. Had a nurse that always did a good job, frequently went above and beyond, patients loved him. He did the wrong thing at the wrong time in front of too many people...let's just say it was a very scary situation. I had no choice but to go to the bosses boss. He was placed on administrative leave. Know what happens when someone is placed on admin leave? They scour everything, go through computers, HIPPA bins etc looking for evidence. When he returned a week later they handed him a box with his stuff and said here's your final check the police officer will escort you out. All those times of doing what he thought was right, driving to work in an ice storm, didn't matter.